2 out, 3 reprimanded at VA hospital

By Jeremy Redmon

The Atlanta Journal-Constitution

Published: August 8, 2013

Two Veterans Affairs officials have retired, three have been reprimanded and others are facing unspecified “actions” after reports of rampant mismanagement and patient deaths at the Atlanta VA Medical Center in Decatur, a top VA official said Wednesday.

“There are number of actions, which are still in the process,” Robert Petzel, undersecretary for health for the VA, said at a congressional hearing in Atlanta.

Petzel declined to identify the VA officials involved and said he could not offer more specifics, citing privacy laws. The head of the hospital and mental health director have been replaced within the past year, but it was not clear whether they were among the officials Petzel was referring to.

He defended the Atlanta VA Medical Center, saying it has made numerous improvements since the findings.

Also at Wednesday’s hearing, an Army veteran working for the Wounded Warrior Project said patients are still waiting too long between appointments and are too seldom getting the individual mental health care they need at the VA hospital in Decatur.

U.S. Sen. Johnny Isakson led Wednesday’s hearing at Georgia State University in downtown Atlanta. Hundreds of veterans and others attended. Isakson called for the hearing after federal inspectors issued scathing audits about the Atlanta VA Medical Center in April. The audits linked pervasive mismanagement to the deaths of three veterans at the 405-bed hospital.

In one case, a man who was trying to see a VA psychiatrist who was unavailable was told by hospital workers to take public transportation to an emergency room. He never did and committed suicide the next day. Another man died of an apparent drug overdose after providers failed to connect him with a psychiatrist. And a third patient died of an overdose of drugs given to him by another patient. The death of a fourth veteran, who committed suicide in a hospital bathroom, later came to light.

The audits found many of the 4,000 veterans the hospital referred to outside mental health facilities “fell through the cracks.”

A separate report from the Joint Commission, a national organization that accredits hospitals, documented dozens of safety problems at the center this year, including fire hazards and unsecured prescription narcotics.

The federal audits prompted U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs, to tour the hospital in May along with four Georgia congressmen. Miller’s committee plans to hold a hearing in Pittsburgh on Sept. 9 to examine lapses in care at VA medical centers in Georgia and across the country.

Several federal lawmakers have called for heads to roll at the VA Medical Center in Decatur, a hospital that serves roughly 90,000 veterans and is the largest such facility in the Southeast.

The new director of the Decatur VA hospital, Leslie Wiggins, who took the job on May 20, said last month that a 17 additional mental health providers had been hired and a new patient tracking system had been implemented since the audit reports.

“I cannot say that I think anyone should be fired, ” she said last month. “The employees … regret the loss of any veteran. The organization is taking the whole matter very seriously.”

Petzel, who oversees the nationwide VA health system, disclosed the retirements and reprimands Wednesday in response to questions from Isakson. While he declined to offer specifics, Petzel said he had shared additional details with the Senate Veterans’ Affairs Committee.

Isakson confirmed he had reviewed that information, calling it private. He said the retirees had worked at the “ground-level” and in the administration at the hospital. An Isakson spokesman said they were “allowed” to retire.

Isakson also disclosed three VA officials have been reprimanded for either “negligence or failure to follow instructions.”

Isakson concluded his line of questioning at the hearing by asking: “Is the VA committed to pursuing those accountability hearings and those processes?”

Petzel responded: “Absolutely, sir.”

Petzel said the VA hospital in Decatur has strengthened its policies and is working to improve patient safety. But Vondell Brown, alumni manager for the Wounded Warrior Project, testified there are still gaps in mental health care there.

“What I often hear from warriors is it is difficult to get appointments when they need them, being handed from one mental health provider to another, difficulty in developing rapport with providers — and they are being offered medication to ease symptoms rather than getting talk therapy that might help resolve deeper problems,” he said.

Several Georgia veterans who attended Wednesday’s hearing said they are seeing improvements.

“They are headed in the right direction,” said Leon Booker, of Morrow, a Navy veteran who goes to the Atlanta Medical Center for help and works with Disabled American Veterans, a veterans assistance group. “Now they have things in place to make things a lot better for the veterans in terms of service and follow-up with the doctors and the clinicians.

“They listen to you. They actually listen to you now. That is what is most important – someone to listen to your concerns and give you the proper medical treatment without such delay.”

Much of Wednesday’s hearing focused on mental health care for veterans. At one point, Georgia’s adjutant general testified that 18 Georgia National Guardsmen have committed suicide over the past decade. One Georgia guardsmen attempted suicide in the past month, said Maj. Gen. Jim Butterworth.

Butterworth testified about the Guard’s efforts to prevent suicides. He said most of the suicides and attempted suicides in his organization appear to have been related to finances or personal relationships.

“Unfortunately,” he said, “suicide is a real and ongoing tragedy within our military family.”